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Adult Intestine Transplant Candidate Registration Worksheet
FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 12/31/2011
Note: These worksheets are provided to function as a guide to what data will be required in the online TIEDI ® application. Currently in the worksheet, a red asterisk
is displayed by fields that are required, independent of what other data may be provided. Based on data provided through the online TIEDI® application, additional
fields that are dependent on responses provided in these required fields may become required as well. However, since those fields are not required in every case,
they are not marked with a red asterisk.
Provider Information
Recipient Center:
Candidate Information
Organ Registered:
Last Name:
Date of Listing or Add:
MI:
First Name:
Previous Surname:
SSN:
Gender:
HIC:
DOB:
Male
State of Permanent Residence:
Permanent ZIP Code:
Is Patient waiting in permanent ZIP code:
-
YES
NO
UNK
Ethnicity/Race:
(select all origins that apply)
American Indian or Alaska Native
Asian
American Indian
Asian Indian/Indian Sub-Continent
Eskimo
Chinese
Aleutian
Filipino
Alaska Indian
Japanese
American Indian or Alaska Native: Other
Korean
American Indian or Alaska Native: Not Specified/Unknown
Vietnamese
Asian: Other
Female
Asian: Not Specified/Unknown
Black or African American
Hispanic/Latino
African American
Mexican
African (Continental)
Puerto Rican (Mainland)
West Indian
Puerto Rican (Island)
Haitian
Cuban
Black or African American: Other
Hispanic/Latino: Other
Black or African American: Not Specified/Unknown
Native Hawaiian or Other Pacific Islander
Hispanic/Latino: Not
Specified/Unknown
White
Native Hawaiian
European Descent
Guamanian or Chamorro
Arab or Middle Eastern
Samoan
North African (non-Black)
Native Hawaiian or Other Pacific Islander: Other
White: Other
Native Hawaiian or Other Pacific Islander: Not
Specified/Unknown
White: Not Specified/Unknown
U.S. CITIZEN
Citizenship:
RESIDENT ALIEN
NON-RESIDENT ALIEN, Year Entered US
Year of Entry to the U.S.
NONE
GRADE SCHOOL (0-8)
HIGH SCHOOL (9-12) or GED
ATTENDED COLLEGE/TECHNICAL SCHOOL
Highest Education Level:
ASSOCIATE/BACHELOR DEGREE
POST-COLLEGE GRADUATE DEGREE
N/A (< 5 YRS OLD)
UNKNOWN
IN INTENSIVE CARE UNIT
Medical Condition at time of listing:
HOSPITALIZED NOT IN ICU
NOT HOSPITALIZED
Patient on Life Support:
YES
NO
Ventilator
Artificial Liver
Other Mechanism, Specify
Specify:
Functional Status:
No Limitations
Limited Mobility
Physical Capacity:
Wheelchair bound or more limited
Not Applicable (< 1 year old or hospitalized)
Unknown
Working for income:
YES
NO
UNK
If No, Not Working Due To:
Working Full Time
Working Part Time due to Demands of Treatment
Working Part Time due to Disability
If Yes:
Working Part Time due to Insurance Conflict
Working Part Time due to Inability to Find Full Time Work
Working Part Time due to Patient Choice
Working Part Time Reason Unknown
Working, Part Time vs. Full Time Unknown
Within One Grade Level of Peers
Delayed Grade Level
Academic Progress:
Special Education
Not Applicable < 5 years old/ High School graduate or GED
Status Unknown
Full academic load
Reduced academic load
Academic Activity Level:
Unable to participate in academics due to disease or condition
Not Applicable < 5 years old/ High School graduate or GED
Status Unknown
Previous Transplants:
Organ
Date
Graft Fail Date
The three most recent transplants are listed here. Please contact the UNet Help Desk to confirm more than three previous transplants by calling 800978-4334 or by emailing [email protected].
Previous Pancreas Islet Infusion:
YES
NO
UNK
Source of Payment:
Primary:
Specify:
Secondary:
Clinical Information: AT LISTING
Height:
ft.
in.
cm
ST=
Weight:
BMI:
lbs
kg/m
kg
2
ABO Blood Group:
Primary Diagnosis:
Specify:
Secondary Diagnosis:
Specify:
General Medical Factors:
No
Type I
Type II
Diabetes:
Type Other
Type Unknown
Diabetes Status Unknown
No dialysis
Hemodialysis
Dialysis:
Peritoneal Dialysis
Dialysis Status Unknown
Dialysis-Unknown Type was performed
No
Yes, active within the last year
Peptic Ulcer:
Yes, not active within the last year
Unknown
ST=
No
Yes, and documented Coronary Artery Disease
Angina:
Yes, with no documented Coronary Artery Disease
Yes, but Coronary Artery Disease unknown
Status Unknown
Drug Treated Systemic Hypertension:
Symptomatic Cerebrovascular Disease:
Symptomatic Peripheral Vascular Disease:
Drug Treated COPD:
Pulmonary Embolism:
Any previous Malignancy:
YES
NO
UNK
YES
NO
UNK
YES
NO
UNK
YES
NO
UNK
YES
NO
UNK
YES
NO
UNK
Skin Melanoma
Skin Non-Melanoma
CNS Tumor
Genitourinary
Breast
Specify Type:
Thyroid
Tongue/Throat/Larynx
Lung
Leukemia/Lymphoma
Liver
Hepatocellular Carcinoma
Other, specify
Specify:
Most Recent Serum Creatinine:
Total Serum Albumin:
mg/dl
ST=
g/dl
ST=
Intestine Medical Factors
Exhausted Vascular Access:
Liver Dysfunction:
Intestine Neoplasm:
History of Portomesenteric Vein Thrombosis:
History of TIPSS:
YES
NO
UNK
YES
NO
UNK
YES
NO
UNK
YES
NO
UNK
YES
NO
UNK
| File Type | application/pdf |
| Author | bryantpc |
| File Modified | 2011-11-28 |
| File Created | 2011-11-28 |